INTERNATIONAL CONFERENCE ON MEDICAL ASPECTS OF TELEMEDICINE ABSTRACTS The first international conference on medical aspects of telemedicine, "Telemed93", was held in Tromsx 20th-22nd may 1993, at the worlds nothern-most University. Telemed93 was initiated and organized by the university hospital of Tromsx and the Norwegian Telecom Research. About 250 persons from 20 different countries attended Telemed93. The 69 abstracts from the conference is divided in three parts which will be posted to this newsgroup. The idea behind this posting is to help you to get information about telemedicine projects all over the world and the field telemedicine in general. Together with this posting you will find the introduction note given by the chairman of the scientific programme committee. NB! The text is coded in ISO-8859, Latin1. Regards Frode Kileng Norut Information Tech., NORUT Research Group Tromsx, Norway ------------------------------------------------------------------ To the participants of the conference! On behalf of the scientific committee it is a great pleasure to welcome all participants from 20 countries to the first international conference on medical aspects of telemedicine. It has been the policy of the committee that by this early stage of telemedicine as many scientific contributions as possible should be subject for oral presentation to achieve a good atmosphere and a sound basis for fruitful discussions during the conference. The program is therefore basically built up around lectures in plenary and parallel sessions in addition to a work shop session including demonstrations of telemedical work-stations. The committee appreciate the many abstracts submitted to the conference which show the large variety and potential of telemedical applications within different aspects of medicine and health care. We hope that the conference will be a good and memorable commitment for further development of telemedicine, contributing to a better health care service for all people in the future. Tor J. Eide Professor chairman scientific programme committee Tromsx 7th of May 1993 Received: from fpsp.fapesp.br by ccvax.unicamp.br (PMDF #2801 ) id <01GZNR9A3HWG8WW22G@ccvax.unicamp.br>; Tue, 22 Jun 1993 00:49:29 BSC (-0300 C) Received: from lion.cce.usp.br (MAILER@BRUSPVM) by brfapesp.bitnet with PMDF#10108; Tue, 22 Jun 1993 00:18 BSC (-0300 C) Received: from BRUSPVM.BITNET by lion.cce.usp.br (Mailer R2.10 ptf000) with BSMTP id 5571; Mon, 21 Jun 93 18:33:10 BD2 Date: 21 Jun 1993 12:35:46 +0000 (GMT) From: Frode Kileng Subject: Abstracts from Telemed93, Introduction. Sender: Hospital Computer Network Discussion Group and Data Base To: Multiple recipients of list HSPNET-L Reply-to: Hospital Computer Network Discussion Group and Data Base Message-id: <1B31C1FA60008186@brfapesp.bitnet> X-Envelope-to: INFOMED, SABBATINI Content-transfer-encoding: 7BIT Comments: Warning -- original Sender: tag was NETNEWS@AUVM.AMERICAN.EDU Abstr. no 1 - MODERN COMMUNICATION THEORIES Sven Windahl, Associate Professor, University of Lund, Sweden Communication is treated within several scientific disciplines, and there are consequently a wide variety of communication theories. My lecture here on modern communication theory will confine itself to theories found within sociology and social psychology. A common trait in the developmental history of communication theory is the change away from a mostly sender-oriented to a more receiver-oriented perspective. Over the years one has come to ask less what communication does to people than what people do to communication. Also, communication is less depicted as a one-way process than a two-way one. Further, the emergence of new media has directed interest to models of consultancy and supply as contrasted to traditional distribution models. Early versions of communication theory had effects as its major field of interest. Effects were considered strong and were described according to simple stimulus response models. Today's view is that major communication effects are hard to create and that the types of potential effects are different and more complicated than those thought of in early days. Finally, the image of man as taking part in communication has changed. Modern communication research takes as its point of departure that the receiver is creative and that the sender will have great difficulty in predicting receiver response. /* --------------------------------------------------------------------- */ Abstr. no 2 - THE PHYSICIAN WORKSTATION AS A PROFESSIONAL PRODUCTIVITY TOOL Ronald S. Weinstein, MD, Department of Pathology, University of Arizona College of Medicine, Tucson, Arizona, USA A workstation can be defined as a piece of equipment which allows the user to perform tasks and manipulate data. The concept of the professional workstation is a product of the information revolution. Currently, PC-based workstations provide a platform for many medical applications. Ideally, the physician workstation of the future will permit review and manipulating of all patient data, including imaging studies, with ease using a single multifunctional workstation. The installation of integrated services digital networks (ISDNs) within the health care system is a step toward this goal. ISDNs allow a physician to access a variety of computer systems within a medical center and elsewhere from a single workstation by merely identifying which database is desired. Patient information in the form of a bassinet-to-grave electronic medical record, including laboratory data, x-rays, and pathology specimen images, will become readily available to the physician. Such workstations can significantly increase the efficiency of physicians and other health care workers, and facilitate the dissemination of high quality medical services. /* --------------------------------------------------------------------- */ Abstr. no 3 - THE HISTORICAL DEVELOPMENT OF TELEMEDICINE Max House, MD, FRCPC, Memorial University of Newfoundland, St. John's, Newfoundland, A1B 3V6, Canada The term "telemedicine" is used to include all types of communication over distances that support health care and health education. Since the discovery of the telephone, telecommunications have played an important role in health care; however, organized telemedicine projects and services began in the late 1950s and 60s and greatly increased during the early days of space exploration. The United States' Applications Technology Satellites ATS I and ATS VI were used for impressive demonstrations in the late 60s, and in the late 70s, the Communications Technology Satellite (a joint US/Canada project) was used for telemedicine experiments in both the US and Canada. By the beginning of the 1980s, there had been a number of demonstrations showing the effectiveness of ground-based and satellite systems with a range of transmission bandwidths being used. Not surprisingly, in the medical profession there were differences of opinion as to the effectiveness of available systems. Some researchers believed that only two-way interactive full motion television was adequate while others pointed to the high cost of broadband transmission and showed that distance health care could be enhanced using inexpensive narrowband technologies. The latter was shown to be particularly effective for distance health education. In the past decade there have been a number of successful experiments and demonstrations mounted to meet non-urban and remote health needs which include - consulting services; clinical laboratory resources; investigative techniques (e.g. ECG, EEG, radiology, ultrasound, nuclear medicine); continuing education; training programmes for allied health professionals and community health education. Teleradiology, regarded as an important need, has received the most attention. While slow scan television (analogue and more recently digital) has had moderate success, there has not been widespread acceptance of this technology. Electrocardiograms and electroencephalograms have been effectively transmitted for more than two decades. With the availability of interactive video there has been a recent increase in tele-consultations. With digitization of telephone networks and the development of compressed video, there has been a major resurgence in interest in telemedicine. These systems are also effective for distance education. With the development of multimedia units and telephone "switches" which allow the transmission of voice, data and video, telemedicine appears to be coming to maturity. /* --------------------------------------------------------------------- */ Abstr. no 4 - SYNAPSE HEALTH RESOURCES ONLINE Robin K. Meter, University of Nebraska Medical Center, 600 South 42nd Street, Omaha, Ne USA 68198-5030 The University of Nebraska Medical Center, a major unit of the University of Nebraska, serves the Midwest through its programs in health professions education, research, patient care and community service. To provide health education and patient care information to isolated rural areas of the region, a comprehensive health information network was developed (Synapse Health Resources Online). The network is in it's fourth year of operation. Utilizing personal computers, modems and standard telephone lines, Synapse connects over 400 physicians and health care professionals throughout the central United States to UNMC. Databases that can be accessed/utilized include electronic mail, medical library holdings and literature, bulletin boards, drug information, continuing medical education, and decision support. In addition, physicians who refer patients to the Medical Center can continue to track their care by accessing their test results and discharge summaries through the Synapse network. Synapse is also used extensively to support the Medical Center's rural health training initiatives. Over 90 rural sites are utilized as training environments for students in all health-related disciplines. To support these teaching and clinical experiences, UNMC also utilizes two-way interactive video and audio. These capabilities are provided by a satellite transponder owned and operated by the state of Nebraska. In addition, the Nebraska Video Teleconferencing Network, a land-line based interactive video system, has recently been developed in the state. The network will provide plentiful opportunities for extended consulting for the Medical Center. UNMC also utilized personal computers and telephone lines to provide distance consulting and monitoring of cardiology patients. Currently, O'Neill, Nebraska, a town of approximately 5,000 people 200 miles from Omaha, is fully operational. The Medical Center hopes to add three additional sites in the next two years. Currently, Synapse has over 400 users in over 150 sites in six states. To manage the network, the Synapse Department maintains 5.1 FTE's. /* --------------------------------------------------------------------- */ Abstr. no 5 - STANDARDISATION IN HEALTH CARE TELEMATICS Sigurd From, Norwegian Telecom Research A large number of telemedicine applications have been developed in research and development projects around the world. Some of these have been turned into commercial products for sale on the health care market. However, today's lack of standards for health care telematics allow only users buying all the same products to communicate with each other. This situation creates high costs on products, uncertainly among the users whether to invest in a product, and reduces the market opportunities for products. In order to create a market for telemedicine products, applications and services, standards are needed. The standards required may be separated in two categories: health care specific standards such as medical concept definitions, medical codes and medical message descriptions and telematics standards such as image, sound and text interchange formats and network standards. The European Committee for Standardisation (CEN) established in 1990 is a Technical Committee for Medical Informatics (CEN/TC 251). CEN/TC 251 follows a program of developing both health care and telematics standards. Today more than 450 individual experts are active in this work. A first set of standards covering laboratory communication, handling of medical coding systems and standards for interchange and manipulation of radiology images are expected at the end of 1993. /* --------------------------------------------------------------------- */ Abstr. no 6 - CURRENT ISSUES REGARDING TELERADIOLOGY Joseph N. Gitlin, Professor, Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A. Teleradiology usually refers to systems that transmit medical radiographs from one location to another for primary diagnosis. Most of the work to date has involved the scanning of conventional films at medical facilities having no radiologist and transmitting the digitized images to a medical center for interpretation by a radiologist who views the images on a television monitor. Teleradiology systems are also being used with digital modalities such as magnetic resonance and computed tomography to transmit images for preliminary impressions of emergency cases and for hospital consultation. Many of the technical problems associated with early teleradiology systems have been resolved by commercially available products that acquire high resolution images in a "standard" format, transmit large volumes of data at high speeds, store and retrieve images cost-effectively and provide ergonomically designed workstations. However, the issue of clinical acceptance remains, particularly with regard to the accuracy of interpretations resulting from viewing images on electronic screens. Three recent studies at Johns Hopkins showed that the accuracy of interpretations of chest and bone examinations on film was significantly different from that associated with interpretations of the same cases viewed on screens. Based on these results, specific improvements in resolution, speed and enhancements have been identified to increase the accuracy of screen readings and the related confidence of the radiologist. /* --------------------------------------------------------------------- */ Abstr. no 7 - TELEMEDICINE AT THE MEDICAL COLLEGE OF GEORGIA, USA Daniel F. Ward, MD, Jay Sanders, MD, Elizabeth Michael, Center for Telemedicine, Medical College of Georgia, Augusta Georgia, 30912, USA To improve health care in the largest state east of the Mississippi River the Medical College of Georgia [MCG] began a telemedicine program in November 1991. It uses interactive compressed video over T-1 lines with peripheral attachments which allow physical examination, except palpation, and the transmission of optical, static, and dynamic images. The base station is in the Emergency Department [ED] of MCG. The ED of Dodge County Hospital is the site of the initial demonstration project. A second rural hospital is coming on line, a third planned. Two prison sites are coming on line and a transportable remote module is completed and ready to support rural clinics which do not warrant a permanent installation. Current utilization is to bring specially consultation to generalist physicians. Emergency consultations by in-house specialty fellows and Emergency Medicine Faculty round the clock are beginning. Presently there have been about two hundred consultations, mostly subspecially Internal Medicine, and mostly from the initial demonstration site. Both outpatients and inpatients are being seen. Better than 80% of the patients are being managed in their community and do not require transferal to tertiary centers. /* --------------------------------------------------------------------- */ Abstr. no 8 - TELEMEDICINE IN NORTHERN NORWAY Steinar Pedersen, MD, Head of Department of Telemedicine, University Hospital of Tromsx, N-9038 Tromsx, Norway The geographical characteristics of Norway, the lack of medical expertise in rural areas and the pattern of settling guided the Norwegian Telecom Research (NTR) to initiate The Norwegian Telemedicine Project in 1988. An expert group which came into being through a very close relationship between NTR and the medical experts at The University Hospital of Tromsx (UiTx), Norway, has developed Telemedical applications within many fields of medicine. Based on a broadband network at 2 MBps the video conference system is the basis for a regular contact between remotely situated general practitioners and doctors at UiTx in the fields of dermatology, otorhinolaryngology and psychiatry. In the fields of echo cardiology, radiology and pathology there is regular contact between county hospitals in rural areas in the northern part of Norway and the medical experts at UiTx. Promising trials have been done within the fields of microbiology, gastroenterology and neurosurgery. Remote teaching is regularly used to remote areas in nursery. Trials are being done for broadcasting lectures for the medical students. The different technical solutions seems to work satisfactorily. The quality of images from the remote medical examination has been studied and found good enough to secure a qualified medical diagnosis. The patients are satisfied being diagnosed in this way. The payment and the laws for such services are suggested. It is the organising of the health care system that is the main hindrance for utilising the enormous potential that modern communication can offer to the best for the patients and society. /* --------------------------------------------------------------------- */ Abstr. no 9 - INTEGRATION OF TELEMEDICINE SYSTEMS INTO PATIENT DATABASES Kenneth J. Bloom, MD, Rush Medical College, Chicago, IL, USA Images are an integral part of patient management. With increasing emphasis on "enterprise-wide" health care, possibly spanning large geographic areas, there is a need for a new breed of information system. This information system must be capable of storing the lifetime clinical record of a patient, including pertinent imaging and auditory studies, and allow real-time access of that information at all points of service. Telemedicine, the practice of medicine at a site remote from the patient, needs the infrastructure of such an information system before its value can be fully realized. We have developed a model for an enterprise-wide information system utilizing a relational database model. The current database houses clinical information on 1.3 million patients and is readily accessible to the medical staff. Selected images, both static and dynamic, and auditory data are stored in the database as binary large objects, (BLOBs). Several methodologies for storing, compressing, transmitting and viewing BLOBs have been explored with variable success. Standards must be developed and adopted in an "open-architecture" manner so that multi-component telemedicine/information systems can flourish. /* --------------------------------------------------------------------- */ Abstr. no 10 - HUMAN PERFORMANCE STUDIES IN THE ASSESSMENT OF TELEPATHOLOGY AND TELERADIOLOGY Elizabeth A. Krupinski, Ph.D., University of Arizona, Tucson, AZ, U.S.A. Although there are many aspects of a telemedicine system that need to be assessed in order to establish its utility and effectiveness in the clinical situation, of most concern to the pathologist or radiologist reviewing a case is the quality of the image they must view in order to reach a confident and accurate diagnostic decision. Well-controlled observer performance studies comparing conventional viewing modalities with new digital, video-based modalities must be conducted, preferably using Receiver Operating Characteristic (ROC) analysis techniques, in addition to "test-of-concept" demonstrations. Some of the important factors to consider in the design and implementation of ROC observer performance studies (e.g., case selection criterion, power) will be discussed; as will the results of some observer performance studies dealing with issues relevant to telepathology and teleradiology (e.g., conventional light-microscopy versus videomicroscopy viewing of pathology images; effect of network transmission loss on perception of radiologic images). /* --------------------------------------------------------------------- */ Abstr. no 11 - THE EUROPEAN INSTITUTE OF TELEMEDICINE Louis Lareng, Reni Rettig, & Monique Savoldelli, Dr. Centre Hospitalier Universitaire de Toulouse, 31052 Toulouse Cidex The European Institute of Telemedicine fosters the promotion and the implementation of any technical means and methods facilitating medical practice. It encourages the development of European networks dedicated to care, training and research. It works with the support of expert consultants with a view to study projects and to launch European programs. The Institute is part of the European move encouraging an ongoing collaboration with the various Community partners. Initiatives of networks such as MAC-NET (medical aid at sea), TOXNET (medical aid to poisoned people), SAME-NET (emergency medical care) illustrate some of the achievements obtained under the aegis of the European community. A further goal of this Institute is to upgrade the quality of care thanks to an optimal application of the technical means and medical skills available. The transfer of medical imaging, biological data and clinical examination via videoconferences is currently in use. Remote medical consultation aiming at making a diagnosis or curing people involves experts in one discipline or several experts from different branches of medicine. This permits to have authorized views on problems such as medical evacuation and to set up continuing education training schemes. Videoconference sessions have already been staged by the European Institute of Telemedicine with the hospitals in Athens, the Hospital Centre in Noumea, the hospitals in Paris, Toulouse, Pitrigueux and Rodez. Moreover, telemedicine counts among its priorities the weaving of a well- structured care network both at the regional, national and European level. Such are the targets of the European Institute of Telemedicine for the next future. /* --------------------------------------------------------------------- */ Abstr. no 12 - RESULTS OF GERMAN TELEMEDICINE PROJECTS Dr. eng., Kar-Hinrich Vvge Eng, De*Te*Berkom GmbH, Voltastr. 5, 1000 Berlin 65, Germany Since 1986 the German Bundespost Telekom is funding large Telemedicine Pilot Projects for Remote Expert Consultation, Remote Diagnosis, GP Integration, Multimedia Reference Data Base, Image Pre- and Postprocessing and remote Education and Training in Medicine. The findings have resulted in modelling a platform description of Generic Applications that is basis for further business planning in Telemedicine. The German Experiments show clearly that beyond the medical and telecommunicative integration strategies for security, reimbursement and medical unit organisation have to be tackled before Telemedicine can be successfully extended to the field. /* --------------------------------------------------------------------- */ Abstr. no 13 - THE UTILITY OF TELEMEDICINE AT MAYO CLINIC Erik G. Tangalos, MD, Mayo Clinic/Mayo Foundation, Rochester, Minnesota, USA 55905 In 1986, Mayo Clinic of Rochester, Minnesota, established major group practice sites in Jacksonville, Florida, and Scottsdale, Arizona. To maintain an integrated practice and a common philosophy, a significant commitment was made to invest in a communications system employing advanced satellite technology and equipment. Our approach has been to provide consultative services to all three group practice sites via full-motion analog video. Three transponders on G-Star III now allow for two simultaneous-live programs linking all three group practice sites. The Mayo experience creates a seamless and transparent interface. We have been able to provide face-to-face consultations, review X-rays and live angiography, participate in speech therapy, and link distance sites during interventional procedures. The network has widespread acceptance among physicians and is also used for educational, administrative and research purposes. Regular surveys are conducted to judge the quality of the service. Guidelines have been established to determine user priority and extensive records exist documenting utilization rates by event, department and time. There are still significant ethical, legal and jurisdictional problems to surmount regarding the long distance consultative practice of medicine and the delivery of medical services via telecommuni-cation systems. Multiple trials are underway on campus, in the state and across the nation to explore the various modalities to deliver medical services. From 386 Kbps to 110 Mbps with NASA and the ACTS satellite Mayo experiments are ongoing. Policy issues and acceptable standards are an integral part of the evaluative process and a requirement for reimbursement. Cost, outcome, and liability will be equal determinants in decision making for the future. /* --------------------------------------------------------------------- */ Abstr. no 14 - THE IMPORTANCE OF VISUAL PERCEPTION IN EXPERT DECISION PROCEDURES K. Kayser, Department of Pathology, Thoraxklinik, D-6900 Heidelberg, Germany Analysis of basic visual data (images) is strongly related to transmission of information between a sender (basic image) and a receiver (expert). It can be divided into rank-ordered steps which start with separation of "information- containing areas" (areas associated to basic structures, first-order information). This first perception step is called segmentation, and can be performed with predefined decision rules or (more efficiently) by "filtering specific information wanted from the receiver". The second perception step uses "classification rulers" and groupes the identified objects into various schemes defined by the receiver. Besides identification and classification of certain objects, analysis of their spatial relation (structure) identifies "higher-ordered objects" which can then be classified again. The association of various classified objects results in a generalized conception or diagnosis (third step). Identification, classification, and analysis of interobject relations are the basic procedures needed for any expert decision system and are independent from the rules applied within any of these systems. /* --------------------------------------------------------------------- */ Abstr. no 15 - DESIGN OF GLOBAL COMMUNICATIONS NETWORKS FOR TELEMEDICINE APPLICATIONS Ralph Martinez, Ph.D., Electrical & Computer Engineering, Department and the Department of Radiology. The University of Arizona, Tucson, Arizona, USA A Global PACS is an international network which interconnects several PACS networks at medical and hospital complexes using a global backbone network. A Global PACS environment enables new and beneficial operations between radiologists and physicians when they are located in different geographical locations. This paper presents 3 new user scenarios which enable remote consultation and diagnosis between radiologists at a local PACS site and a remote PACS site. One scenario allows the radiologist to view the same image folder at both local and remote sites so that a diagnosis can be performed. The paper describes the user interface, database management, and network communications software which has been developed in the Computer Engineering Research Laboratory and the Radiology Research Laboratory. In the remote consultation and diagnosis operation, a set of images is requested from the database archive system and the images sent to the local and remote workstation sites on the Global PACS network. Once the images are displayed on the workstations, the radiologists use pointing overlay commands, or frames, to point out features on the images. Each workstation transfers these frames to the other workstation so that an interactive session for diagnosis takes place. In this phase, we use fixed frames and variable sized frames to outline an object. The data packets for these frames must traverse the national backbone in real time. We accomplish this feature by using TCP protocol sockets for communications. The remote consultation and diagnosis operation has been tested in real time between the University Medical Center and the Bowman Gray School of Medicine, at Wake Forest University, over the Internet. In this paper, we present performance data based on tests between these two sites, and show the feasibility of the operation in a Global PACS environment. Future improvements to the system will include real-time voice and interactive compressed video scenarios and the use of ATM/SONET communications systems. This work is sponsored by the National Science Foundation and Toshiba Medical Systems Division. /* --------------------------------------------------------------------- */ Abstr. no 16 - A COMMUNICATION ARCHITECTURE FOR TELEMEDICINE SYSTEMS George Orphanos, Dimitris Kanellopoulos, Stavros Koubias, George Papadopoulos, Applied Electronics Laboratory, Department of Electrical Engineering, University of Patras, Patras 26500, Greece The impressive evolution of computing systems and network technologies during the recent years stimulates research and development in the field of telemedicine systems. Telemedicine is applied whenever a physician located in a health care center of a rural area, wishes due to an emergency, to consult the opinion of an expert located in the regional hospital of a remote urban area. Thus, a network infrastructure is required to support this human-to-human collaboration. Network infrastructure comprises of both the available broadband networks technology now and in the future, and the upper layer communication protocols capable to support multimedia interactive calls. It is apparent that diverse types of traffic (e.g. voice, still images, mouse coordinates, text) coexist within the network infrastructure. Integrated Broadband Communication (IBC) networks link medical workstations located within local or remote sites in order to support a variety of potential applications. This work presents a communication architecture capable to support multimedia medical applications embedded into UNIX-based workstations. The proposed architecture is expected to facilitate the writing of medical applications with the provision of an integrated and universal set of communication services. In order to provide communication services not contingent upon any specific implementation (computer environment, operating system, and network implementation) and manufacturer particularities an "open" development environment is used. OSI Reference Model's adaptation is considered in this work as the basis for the development of enhanced multimedia-oriented communication protocols. Upper layer communication and resource management aspects are analyzed. ISDN network capabilities are proposed as the service-provider for upper layer protocols. The abstraction of a standardized ISDN Application Programming Interface (API) is considered. /* --------------------------------------------------------------------- */ Abstr. no 17 - REMOTE CONSULTATIVE NETWORK. P. Jennett, R. Swanson, M. Watanabe, Faculty of Medicine, University of Calgary, Calgary, Canada Specific study objectives: To describe a patient contact distance consultative service between health care providers practising in a rural site and specialists in an urban centre. Project Methodology: The Remote Consultative Network uses two-way computerized video integrative technology. The model acquires, stores, retrieves, manipulates, and transmits alphanumeric, still image, video, and audio data in real-time and/or off-line models. Professional (elective, urgent, and emergent) and technical (e.g., ultrasound, fetal monitoring, ECG/EEG, stereostethoscopic, funduscopic, microscopic images, labs, and x-ray) consultations are provided. Each service encounter is treated as a critical incident. Descriptive quantitative and qualitative data are collected each time the service is used. Details regarding the frequency and time of service use, types of encounters, reasons for use, effect of service and quality of technology are assembled. Specific demographic information regarding patient, provider, consultant, and practice site are collected. Information regarding the impact of the service on process of care and patient health status/quality of life are collected by survey methods. Results: This remote consulting service has the potential to contribute to the quality and efficiency of health care delivery by providing real-time second opinions from remote site physicians, reducing the time required for diagnosis and treatment of patients, improving physicians' willingness to practice in a rural environment, and creating an effective tool for enhancing education techniques. Specific data from the first series of mock and real encounters indicate a service impact on quality of care; accurate and speedy transfer of on-line information affecting patient transfer and utilization; as well as type, sequence, and costs of management decisions. /* --------------------------------------------------------------------- */ Abstr. no 18 - ON ISDN CONTRIBUTIONS TO THE SUCCESS OF TELEMEDICINE Sigmund Akselsen, Dr.Scient., Norwegian Telecom Research, Tromsx, Norway Today, telemedicine applications are based on a variety of networks, ranging from the ordinary telephone network to specialized data- and video- communication networks. The cost, availability, ease of use and lack of standardization of network solutions and terminal equipment have been identified as some of the major factors that limit the use of telemedicine. The objective of our work has been to address these factors in order to make telemedicine a realistic and affordable tool for the health service. ISDN is in this respect an obvious solution. Our approach has been to port telemedicine applications to ISDN and in addition develop new tools for telemedicine based on ISDN terminal equipment and communication services. Important results include among other a system for transmission of still images for remote medical consultations, experiences from using ISDN video-phones with add-on equipment (cameras and monitors) and data communications for the health services based on ISDN IP-routers. Our conclusion so far is that ISDN will be a suitable network platform for a majority of existing and future telemedicine applications. Further the availability and relatively low costs of future ISDN telecommunications services and terminal equipment will make telemedicine realistic for the public, i.e. available to a majority of health care personnel and not a curiosity for the chosen few. /* --------------------------------------------------------------------- */ Abstr. no 19 - PERFORMANCE EVALUATION AND NETWORK MANAGEMENT OF PICTURE ARCHIVING AND COMMUNICATION SYSTEMS - PACS Tryphon Chiotis, Theodoros Karounos, Professor Basil Maglaris National Technical University of Athens-NTUA, Department of Electricial and Computer Engineering Division of Computer Science, 15773, Zografou, Athens, Greece. Network Management and Optimal Design Laboratory NETMODE In this paper, we address the congestion problems occurring at high speed networks, mainly because of digital image transfer. Such problems can be efficiently solved by proper design and intelligent management of the related networks. To that end, we present a source model of a typical Picture Archiving and Communication System (PACS), and we use it for a performance evaluation. The particular model is presented gradually, from a simple to a complex source model. Our simulation results and conclusions are compared with calculations based on simple analytical models. Firstly, we handle the communication channel as a simple time sharing system, with Poisson image arrivals. The most important parameter is the network utilization. Next, we introduce sliding window flow control, which transforms the corresponding analytical model to a closed multichain queuing network. Here the main parameter is the window size. Finally, we consider a probable hierarchy of caching to minimise the image retrieval time. From the network management point of view, we study specific "agent" objects (extensions to standard Management Information Base, MIB), giving network management the possibility of monitoring and controlling the PACS system. These objects are functional aggregates of variables such as the number of image servers and image displaying workstations, the mean value and the distribution of the image size, the capacity of the transport network and synchronisation parameters. /* --------------------------------------------------------------------- */ Abstr. no 20 - CREATING A COST EFFECTIVE MEANS OF IMPLEMENTING TELEMEDICINE Aly A. Salam1), & Elizabeth C. Davison2). 1) Chief Operating Officer, American Telemedicine, Inc., 315 Boulevard, N.E., Suite 224, Atlanta, GA 30312 USA, Deputy Director. 2) International Medical Institute, 315 Boulevard, N.E., Suite 224, Atlanta, GA 30312 USA The obstacles to implement a telemedicine system is not only in the up-front costs, but also the ongoing operational fixed overhead. These costs often involve the use of dedicated lines and the need for high band width to transmit live video, data and sound. The associated costs are generally prohibitive for most organizations without subsidized funding. Other problems with such implementations are their closed architecture and incompatibility with other telemedical systems. In researching existing private telemedical systems in the U.S. and reviewing materials from initial trials dating back to the 1970s. American Telemedicine has concluded that the most cost effective and efficient means of implementing telemedicine on a large scale is the use of an open system architecture which: * is based on a multi-media PC platform using windows to create an open and user friendly interface to exchange information without loss of security of confidential information. * Operate in a dial-up mode of communications using either standard analog, switch-56K or ISDN technology (which is more prevalent on the European continent). * Use a delayed video download with real time voice and data exchange making real-time video teleconferencing and consultation optional for those who have a cost effective infrastructure to support real time video exchange. * Bring the up-front per-site capital investment for a total telemedical solution down 60-80% and bring the fixed operating overhead down to hundreds rather than thousands of dollars per month. American Telemedicine has designed such a system in cooperation with physicians, major multinational communication and technology companies. /* --------------------------------------------------------------------- */ Abstr. no 21 - A FRAMEWORK FOR EUROPEAN SERVICES IN TELEMEDICINE M.H. Williams 1), B. Mahr 2), G. Venters 1), D. Lutzebdck 2) 1) Department of Computing and Electrical Engineering, Heriot-Watt University, Edinburgh, United Kingdom 2) Fachbereich 20 Informatik, Technical University of Berlin, Berlin, Germany A great deal of information drawn from various sources must be considered when developing a Telemedicine service, with the risk of serious consequences should any important information be missed. There is a need for a methodology which can provide comprehensive coverage of the multi-disciplinary information that has to be considered when designing, planning developing or installing a Telemedicine service. The framework for European Services in Telemedicine being developed by the FEST project addresses this issue by providing a rational and comprehensive model for Telemedicine services and situating knowledge drawn from the various relevant disciplines within that model. A top-down (reductionist) approach is used to provide the model and a bottom-up (constructionist) approach is used to organise and present the information which populates it. Concepts adapted from Open Distributed Processing (ODP) are used to provide a model of Telemedicine services while the concepts of hypertext and programmed texts are used to organise the input information. In order to provide a comprehensive description of a service, the model describes it from three different viewpoints - the Enterprise viewpoint, the Information and Processing Viewpoint and the Technology viewpoint. Each viewpoint is in turn examined in terms of a number of aspects which allow a complete description of the service as seen from that viewpoint. A series of generic questions relevant to the development of any Telemedicine service provide a means of integrating the two approaches to the framework. The questions form a basis for the organisation of the information and guidance while at the same time being classified in terms of the viewpoints and aspects of the model. Developers of Telemedicine services should be able to use the framework to ensure that they take into account all the factors affecting their service and that they fit into the context of European Telemedicine services as a whole. /* --------------------------------------------------------------------- */ Abstr. no 22 - PLANETARY MEDICINE BY SATELLITE Dr. Peter Jovanovic, Representative of International Astronautical Federation on 46 World Health Assembly, Geneva 1. OBJECTIVE OF THE STUDY was to establish to what extent satellite communications, remote sensing and remote control can be useful in medicine on global scale. 2. AUTHOR PUBLISHED many papers on this subject since 1983, and studied many projects and experiments in several countries. 3. METHOD USED was analyses of: - Capacity of satellite based telecommunications to be directly used for diagnostic, prognosis and therapy in preventive or curative public of private medical practice, public education and professional formation; - Capacity of direct of indirect assessment by remote sensing monitoring of pathogenic environmental parameters; - Capacity of satellite based control of environmental management and sanitary facilities for preventive measures. 4. RESULTS OF THE STUDY confirmed that satellite based technology gives possibility for direct identification and quantification as well as for indirect assessment. 5. AUTHOR'S CONCLUSION was (1984) that results warrant to propose introduction of new term: Satellite medicine as new subject heading. Also proposed to World Health Organization and United nations committee for peaceful use of outer space to adopt general program, action plan and methodology. 6. 1992. Author initiated creation of international association for satellite medicine in order to integrate all various aspects, specific organizations and projects in new medical program. The ultimate goal was to overcome local national and geographic limitations and attaining one interconnected planetary health system for our common home: Earth. Abstr. no 23 - TELEPATHOLOGY TRIAL IN SWEDEN - PRELIMINARY RESULTS Christer Busch 1), and Silas Olsson 2) 1) Department of Pathology, University Hospital, Uppsala, Sweden 2) Spri, The Swedish Institute for Research and Development of Health Services, Stockholm, Sweden In Sweden about 30 acute care hospitals, out of 105 in total, have there own surgical pathology laboratory service regarding cytology and histopathology diagnosis. Along with more specialised and sub-specialised pathology service, the need for consultations between pathologists has increased. Telepathology represents a potential for intensified communication between pathologists. Six telepathology stations with static image transfer mode are being leased and three permanent stations have been purchased and installed. During the trial period, from September 1992 to October 1993, all surgical pathology laboratories in acute care hospitals in Sweden will be testing telepathology. The telepathology workstations selected for this trial are PC-based, and the telecommunication network used is ISDN (64 kbit/sec). The telepathology trial in Sweden is set up to study several conditions e.g. the specific need for telepathology, the practical handling and usage, the image quality, and to study eventually limitations with a static imaging system for consultations between pathologists. A technology assessment study is a part of the trial. In this trial, a study of the expectations among the Swedish pathologists on telepathology is included. Generally, the image quality and the time for image transfer do not seriously limit the possibilities for consultations. Small laboratories have welcomed the possibilities for rapid advice. /* --------------------------------------------------------------------- */ Abstr. no 24 - TELEPATHOLOGY PROJECT IN PORTUGAL Luns Gongalves, M.D., Carlos Cunha, Tech. Eng. Hospital Garcia de Orta, Almada, Lisboa and Hitec Ldt., Oeiras, Portugal. SPONSORS: TELECOM PORTUGAL AND TLP (T. Lisbon and Porto). Portugal is a country where, in many provinces, there are neither Anatomic Pathologists nor Pathology Departments in the District Hospitals. In order to provide such Hospitals with Pathology diagnostics, a telepathology network has been installed with a main center, based on the Pathology Department of the Garcia de Orta Hospital in Lisbon. This main center is connected via a Euro-ISDN network to the Hospitals of Beja, Faro, Castelo Branco and Portimco. Each Hospital system includes a still video workstation comprising a microscope with a TV camera, a computer with a video digitizing board and a Euro-ISDN board, a video monitor and a telephone for audio communication. The main objectives of the project are: 1. To provide frozen sections service and fast cytologic examinations. 2. To allow for interchange of opinions about diagnostic problematic cases specially on the oncological field through a European network (Euro-ISDN). 3. To support the diagnostics by histomorphometry, DNA analysis and Immunocytochemistry. /* --------------------------------------------------------------------- */ Abstr. no 25 - THE USE OF ROBOTIC MICROSCOPY IN TELEPATHOLOGY Ronald S. Weinstein, MD, Department of Pathology, University of Arizona College of Medicine, Tucson, Arizona, USA Incorporation of a remote-controlled, fully motorized light microscope into a dynamic (real time) telepathology system is highly desirable for several reasons. Pathologists can emulate "hands-on" manipulation of a microscope. There is evidence that dynamic imaging using robotic microscopy reduces specimen viewing times and increases the efficiency of telepathology systems. An innovation that has improved pathologist performance using a dynamic telepathology system is digital global specimen maps. At the beginning of a diagnostic session, a low-resolution gross image of the entire microscope slide is captured and transmitted to the receive workstation. This image substitutes for the viewing of slides by holding them up to the light by the pathologist. At the receive site, a red rectangle appears superimposed on the global image. This indicates the position of the objective lens in relation to the slide, and delineates the field of the slide that appears on the video monitor. The global view of the slide functions as a large-scale map of the space to explore, and the red rectangle serves as a "you are here" marker. /* --------------------------------------------------------------------- */ Abstr. no 26 - TELEPATHOLOGY IN NORTHERN NORWAY. EXPERIENCES IN REMOTE FROZEN SECTION SERVICE. I. Nordrum and T.J. Eide, Department of Pathology, University Hospital of Tromsx, Tromsx, Norway. Remote frozen section service is arranged by remote controlling video microscopes with motorized X, Y and Z stage movements, magnification and illumination located at Kirkenes and Harstad Hospitals, at a distance up to 400 km apart from the workstation at the University Hospital of Tromsx. The images of the frozen section are transmitted via a two-ways telephone and video telenetwork with a 2Mbit/s capacity. The images are displayed on a monitor as both still and video images and diagnosed by pathologists in Tromsx. To date, tissue of 74 patients have been examined with frozen section. Correct benign versus malignant diagnosis are given in 67 of 74 cases compared with final diagnosis based on formalin fixed and paraffin embedded material. One false positive and three false negative diagnosis regarding malignancy have appeared in addition to three deferred diagnosis. The average time taken for examination of each frozen section is 13 minutes. For small hospitals with limited requirement of local pathology service and for hospitals with deficiency of specialists, telepathology may be a worthwhile substitute. /* --------------------------------------------------------------------- */ Abstr. no 27 - TELEMEDICINE AND PSYCHIATRY Jane Preston, MD, FAPA, Telemedical Interactive Consultative Services, Inc., c/o MCC, P.O. 200195 Austin, Texas 78720 Interpersonal meaning is the psychiatrist's technical tool for evoking diagnostic material and supporting treatment, psychotherapeutic and psychopharmacological. Accordingly, as a specialty it arguably presents the sternest test of interactive video transmission of medical services. A. History of telepsychiatry in the United States; 1970-1992. B. Technological techniques to augment meaning and treatment results. /* --------------------------------------------------------------------- */ Abstr. no 28 - "TELEPSYCHIATRY" Solveig Wilhelmsen, Ingrid Hoff & Tove Kristiansen, Child Guidance Clinic, The Hospital of Kirkenes, Norway Object: Is it adequate to use videoconferences in therapeutic work with children, parents and professionals as participants? Method: * Participating in the process * Interview with the participants Results:* The attention is more focused on the client * The balance of power between children and adults is disturbed * Less travelling * New methodology developed * Closer follow-up Conclusions: It is adequate to use videoconferences in therapeutic work with children, parents and professionals as participants. _ "Distance creates closeness" /* --------------------------------------------------------------------- */ Abstr. no 29 - EVALUATING A DIGITISED INTERACTIVE VIDEOLINK (LCVC) FOR PATIENT -DOCTOR COMMUNICATION IN AN ACUTE PSYCHIATRIC SERVICE: SELF-REPORT MEASURES P. McLaren, Dr, A.B. Summerfield, Dr, C.J. Ball, Dr. UMDS, Division of Psychiatry, Guy's Hospital, London SE 1, 9RT, UK. Aims: To use self-report measures to evaluate the impact of communicating via the LCVC on patient - doctor communication. Method: Self-report questionnaires were developed for doctor and patient users. The questions were based on responses of users during pilot use of the LCVC. Users completed questionnaires immediately after every interaction on the LCVC. Results: 47 patient questionnaires were suitable for analysis. Over 85% said they felt better as a result of the interaction suggesting effective communication had occurred. 25% reported feeling upset by the LCVC but 15% found it easier to talk to the doctor in this way. 75% were willing to use the LCVC again for the same sort of lask. 44 doctor responses were analyzed. Only 15% felt that the LCVC had not interfered with the task but in 61% of cases the doctors felt confident to make clinical decisions on the basis of the interview. 25% said they would need to see the patient in person to complete the task effectively. Doctors were asked to estimate how upset the patients were by using the LCVC and this correlated poorly with the patient self-reports. In 56% of cases the doctor overestimated the degree of upset caused to the patient. The over-estimators also differed in reporting greater anxiety, self-consciousness and being less confident in establishing a diagnosis. Conclusion: The LCVC was widely acceptable to patients but received a more guarded response from the doctors. Analysis and correlation of doctor and patient data reveal important distortions which require further clarification. /* --------------------------------------------------------------------- */ Abstr. no 30 - EVALUATING A DIGITISED INTERACTIVE VIDEOLINK FOR PATIENT-DOCTOR CONTACT IN AN ACUTE PSYCHIATRIC SERVICE P.M. McLaren, Dr., C.J. Ball, Dr., A.B. Summerfield, Dr., UMDS, Division of Psychiatry, Guy's Hospital, London SE 1 9RT, UK. Aim: This study was performed as part of the Telemed project (RACE-1086). A prototype low cost videoconferencing system (LCVC) was assessed on an acute psychiatric admission ward to determine its potential for remote diagnosis and treatment in psychiatry. Method: The responses of doctors and patients to communicating via an LCVC were assessed by direct observation, CCTV monitoring and video-tape recording. The LCVC connected two adjacent wards with the psychiatrist in one and the patient in another simulating a remote communication. The LCVC was based on a P.C. and generated a monochrome picture with either 64 or 25 grey scales. The output was suitable for transmission down 2 Mbit/s links. Results: 59 patients were asked to use the LCVC and 12 refused. Refusal was more likely with patients suffering from a psychotic illness and/or legally detained. The patients had a broad mix of age and race neither of which was associated with refusal. The detailed reasons for patients refusing will be presented as they represent a complex interplay of mental state, relationship with their doctor and responses to the equipment. Vignettes of patient refusals, user responses and positive and negative side-effects will be discussed. For example, some schizophrenic patients reported finding it easier to communicate over the LCVC while another incorporated it into his delusional system. Conclusions: The reasons for refusal have important implications for the design of studies for the further assessment of such technology. Direct observation revealed unexpected responses which have implications for equipment design and the training of professional users. /* --------------------------------------------------------------------- */ Abstr. no 31 - GENERAL CONFIGURATION OF HOME-BASED DATA ACQUISITION SERVICE Blood pressure model J.L. Weber, M. Noirot, S. LeFaou, Laboratory BERTIN France. Pr. J. Menard, Htpital Broussais, Paris, France The remote and regular acquisition of medical/biological data at the patient's home involves four main parties (emergency assistance is not included). The Family Doctor, who selects the patients for remote monitoring, prescribes the medical indication and keeps all the patient-related measurements. The Coordinating Center, which provides home-based technical and medical assistance for patients. Located near remotely monitored patients, the Center maintains all the equipment for the family doctors and provides home assistance during measurement sessions. The Specialist Center, which helps the family doctors with medical problems and issues a recommendation for each balance of remote measurements. The Server, which remotely provides the family doctors with regular information on the medical monitoring of his patients, the regularity of the measurements, the progress in the various measurement sessions. The server also manages the follow-up operations. The choice was based on various features of these home-based medical and social services. Regular homed-based blood pressure monitoring is an organizational model for remote surveillance. In fact a large number of people are involved. Patient-taken blood pressure measurements have recently been recognized by the World Health Organization as a means for keeping track of the hypertensive population. The widespread use of a remote capture system for physiological data in an everyday environment is a unique case of European health observation being applied to a chronic pathology. The three-fold aim of the French National TAAM/TELESANTE (Remote Health Care) Program sponsored by the Ministries of Health and Research is to evaluate the different situations of remote homed-based medical surveillance, to test the organizational aspects of legal and professional liability, and to evaluate the coordinating infrastructure for the different cases of homed-based medical and social care benefits. For several months now, remote blood pressure surveillance has been used as an evaluation model to outline the organization of a new monitoring service at several experimental sites in France. In Europe, close to 30 million people suffer from high blood pressure, resulting in 100 million consultations every year, of which 15 % concern the appropriateness of the treatment. In 10 % of the cases, the aptness of the drugs prescribed is open to question. /* --------------------------------------------------------------------- */ Abstr. no 32 - TELECONSULTATION OF OTORHINOLARYNGOLOGY PATIENTS. Steinar Pedersen MD, Gjermund Hartviksen MSc, Daniel Haga MD, Unni Holand, Psychologist Telecommunication technology enables trans-mission of high quality medical images over long distances. In our project we utilized this in the development of a remote consultation service for diagnoses of otorhinolaryngology patients. This is done by integrating endoscopic equipment with a network of conference studios operated by Norwegian Telecom. Signals from a video camera attached to the endoscope are transmitted to a remote institution via a 2 Mbit/s circuit. The receiver can see the endoscopic examination on a monitor and influence the control and movement of the endoscope by communicating over a two-way sound and picture connection with the person operating the equipment. Our study has shown that this method of consultation can be used in the clinic with the same degree of reproducibility as in an conventional consultation situation. This enables us to give patients better service at a lower cost closer to their home environment. The patients are satisfied being diagnosed in this way. /* --------------------------------------------------------------------- */ Abstr. no 33 - TELEECHOCARDIOGRAPHY - REMOTE INSTRUCTION IN ECHOCARDIOGRAPHY VIA VIDEOCONFERENCES J.E. Afset, Medical Department, Kirkenes Hospital, 9901 Kirkenes, P. Lunde, Medical Department, University Hospital of Tromsx, 9038 Tromsx, Norway. The object of this study was to evaluate the loss of diagnostic information by teleechocardiography and its potential for training of inexperienced investigators. An inexperienced doctor performed the investigations at a local hospital using a Tochiba phased array system and the ultrasound signals were transferred to a referral hospital 900 km away, where a cardiologist served as an instructor. The instructor was blinded to all patient identifications and later he examined the patients directly. M-mode, two dimensional echo and Doppler data were assessed. Results: 2-D assessment of valvular anatomy agreed in all patients. Assessment of left ventricular dysfunction differed in two of 14 patients. Thrombi were not overlooked. For the M-mode and Doppler measurements, the differences observed did not reach statistical difference. Quantification of mitral regurgitation disagreed in one patient. No diagnosis were missed. In no patients were the differences of importance for the clinical handling of patients. Conclusion: Teleechocardiography can be performed without loss of diagnostic information. Teleechocardiography constitutes an excellent way of teaching and learning echocardiography. Adequate echocardiographic examinations for teleechocardiographic purposes can be made, even by an inexperienced examinator. /* --------------------------------------------------------------------- */ Abstr. no 34 - DISTANCE DIAGNOSIS OF SKIN DISEASES. Edvard S. Falk, Professor dr.med., Department of Dermatology, Institute of Clinical Medicine, University of Tromsx, N-9038 Tromsx, Norway Since 1989 we have regularly performed diagnostic consultations of skin diseases for general practitioners in Kirkenes, a distance of approxi-mately 900 kilometres from Tromsx. Dermatological patients were brought to a studio at the local hospital in Kirkenes. Video images were transmitted via a two-way telephone and video network, which enabled the patient and the doctor in Kirkenes to consult a dermatologist in Tromsx. Until now we have diagnosed and treated approximately 500 patients by this method. Anamnestic information and clinical manifestations were presented in the studio in Kirkenes hospital and transmitted to Tromsx for diagnoses and treatments. The accuracy of televised dermatological diagnosis was tested by comparing the diagnoses made by a dermatologist in Kirkenes to those made by another dermatologist in the studio in Tromsx. In all of 6 cases identical diagnoses were made by both dermatologists. The technical equipment satisfies our demands for remote diagnostics in dermatology as more than 90% of our patients can be given accurate diagnosis and treatment by this method. Moreover, most of the patients are positive to remote consultations, and additionally the general practitioners have pointed out the educational benefit. /* --------------------------------------------------------------------- */ Abstr. no 35 - ARE THE PATIENTS SATISFIED WITH TELEDERMATOLOGICAL CONSULTATIONS? Unni Holand 1) & Svein Erik Stenvold 2) 1) Research Psychologist, Dept. of Telemedicine, University Hospital of Tromsx, Norway. 2) Senior Consultant, Dept. of Dermatology, University Hospital of Tromsx, Norway Between July 1991 and July 1992, 70 patients with skin diseases, living in the region of Sxr-Varanger in Northern Norway, were diagnosed via telemedical services. Dermatologists at the University Hospital in Tromsx performed distance consultations using the telemedical services, after which 70% of the patients answered a questionnaire regarding patient satisfaction. 49% of the patients felt that they would have received more adequate help if the dermatologist had examined them at their local hospital. However, 66% of the patients were satisfied with the telemedical consultation, 18% indifferent, 12% were dissatisfied, and 4% had no opinion. The patients found several advantages with the telemedical consultation, e.g. reduces waiting time, saving of health system resources, and a more thorough examination due to participation of both the general practitioner and the dermatologist. The patients also found it exiting that new technology was used in the consultation. A few disadvantages were found, e.g. lack of personal contact with the dermatologist, uncertainly regarding the thoroughness of the consultation due to the specialist not touching them, and some were uncomfortable being filmed. For a new dermatological examination 44% would prefer a telemedical consultation, 30% would prefer to see the specialist at their local hospital, 18% would like to go to the University Hospital themselves, while 8% did not have any preference. We conclude that the patients, in general, are satisfied with the tele- dermatological consultation, and that they seem reasonably confident with the method. /* --------------------------------------------------------------------- */ Abstr. no 36 - MOBIMED - TELEMEDICINE FOR EMERGENCY CARE B.A. Sjvqvist 1), M. Dellborg 2), O. Grauers 3), B. Kornhall 3), K. Lindecrantz 1), L. Nordgren 4), S.B. Olsson 3) 1) Found. for Biomed. Eng., Chalmers Univ. of Tech., S-412 96, Gvteborg, Sweden 2) Dept. of Card. Vstra Sjukhuset, Gvteborg, Sweden 3) Dept. of Card. Univ. Hospital, Lund, Sweden 4) Dept. of Clin. Physiol., Univ. Hospital, Uppsala, Sweden In most acute diseases an early and correct diagnosis, and a rapid initiation of an adequate therapy is essential for the outcome of the complete medical treatment. By using telecommunications, telemedicine, it is possible to advance the time for diagnosis and the commence of therapy in many situations. It also enables the distribution of expert knowledge far out into the care organisation as well as to more effectively control transports of patients. Mobimed is a telemedicine system primarily intended for use in emergency care, and especially emergency ambulance care. It uses a standardised user interface, and is designed to handle different kinds of medical information (physiological signals, written messages, forms, etc.) and support consultation between stationary and mobile PC based units. Thereby a better, more qualified, and individually adopted therapy is possible. Mobimed can use various communication channels by changing software modules. For ambulance purpose Mobitex, a digital mobile packet switched network, has been used. Mobimed is presently running at three locations in Sweden. One implementation, in Uppsala county, has been running since 1989 and is intended as a general support system for ordinary ambulances. The two others, in Gvteborg and Lund, are dedicated to early acute myocardial infarction treatment delivered by specialised personnel in specialised vehicles. For Lund a portable Mobimed unit, sized as a briefcase, has been designed. It contains PC, full channel ECG and communication equipment. From this unit contact can be established with the experts at the cardiology unit and thereby it is possible to make an early diagnosis and perhaps commence qualified treatment already in the patients home. /* --------------------------------------------------------------------- */ Abstr. no 37 - DIFFERENCES BETWEEN PUBLIC AND PRIVATE GENERAL PRACTITIONERS IN THE USE OF TELEPHONE Merten Kvist, Department of General Practice, University of Turku, Lemminkdisenkatu 1, SF-20520 Turku, Finland In order to study the volume and content of the telephone service in primary health care, 40 publicly employed health center physicians in Turku and five general practitioners in the private sector at two large private clinics participated in the present study. All telephone contacts during normal working hours were registered during the course of one week. The general practitioner filled in a form immediately after the telephone call terminated and a questionnaire was mailed to the patient. During the course of one week 2047 calls were registered in the public sector and 136 in the private sector. In the public sector the total number of calls per doctor exceeded the corresponding number in the private sector and the patients contacted their general practitioner more promptly. In the private sector the patients felt that the general practitioners were more polite and they listened more attentively. The general practitioners also met the patients' expectations to a higher degree, problems were more adequately solved, the advice given was more business-like and patients were on the whole, more satisfied with the telephone contact than was the case in the public sector. /* --------------------------------------------------------------------- */ Abstr. no 38 - THE PROBLEMS OF DEVELOPING TELEMEDICINE IN HUNGARY Pal Simon, Dr., MD, Ph.,Sc., National Public Health Centre, Budapest, Hungary The application of Telemedicine, as a rapidly developing field of Health Informatics, cannot happen without problems in a country with an informatics infrastructure level lower than average, as it is in Hungary. Health care system - including also Health (Medical) informatics - usually was not among the sectors of high priority developments. In the course of some modest developments in informatics it was not the medical need that determined the choice of the informatical means to be purchased. On the contrary: health care system has received some kind of informatical means (hardware or software) what the professionals tried to apply in medicine. The goal is now to determine those medical fields for which Telemedicine could serve as a good support: emergency care; providing communication between divided databases; providing accessibility to knowledge-bases. /* --------------------------------------------------------------------- */ Abstr. no 39 - HELLENIC RED CROSS SMART CARD Vasiliki Karounou, Professor Basil Maglaris, National Technical University of Athens - NTUA, Department of Electrical and Computer Engineering, Division of Computer Science, 15773, Zografou, Athens, Greece, Network Management and Optimal Design Laboratory - Netmode. Tel./Fax: +301-7790-186. In this paper we present an experimental project for the application of Smart Cards within the Hellenic Red Cross(HRC) Services. The Smart Card was considered as a promising candidate for creating a portable Health Care File among HRC Health Care Services; it was seen as a "data base record" shared among the different Services with the patient being the "transport information network". In order to aid health care delivery in emergency situations as well as in day-to-day care, the HRC Medical File has been introduced with a data set composed of the following five main categories of data elements: Personal Identification, Personal Health History, Family History, Life Style and Life Habits and Current Medical Problems. All medical information changes are recorded over time. The project addresses two application areas: The Telemedicine Service for small remote islands and The Home Nursing Care Service in Athens. The use of the Card will allow the transfer of information between the Hospital, the Home Care Doctor, the Nurse and the Gerontology Service Staff, either at the patient's home or at a medical service site. The Smart Card System will be available on a Lap - top computer for use in home visits. The Smart Card design complies to existing ISO standards (7816-1,2,3, 1987, 88,89 respectively). The hardware platform consists of a microcomputer or a Lap-top connected with a stand-alone card reader/writer. The application software is designed to perform the following functions: Data Entry of a new patient medical file in the Data Base (DB), Retrieval of the Medical file from the Card and loading to the DB, Management of the Medical file and Smart Card Update. The information of a patient exists in the DB up to the point is stored in the Card. The main expected benefit from using the Smart Cards is an increase of consultation effectiveness. The final evaluation will be done by Attitude Questionnaires to medical professionals and patients, in conjunction with measurements on the use of the Card system during every consultation. /* --------------------------------------------------------------------- */ Abstr. no 40 - MODERITIES AND QUALITIES OF TELEMEDICINE Kajiwara, Ken'ichiro, Department of Medical Informatics, Kurume University Hospital, Kurume, Japan Recent advances of computer and telecommunication environments allowed us to perform telemedicine theoretically. There exist so many modalities to pursue these projects to combine with. How to choose these is depended on the needs of whom he wants to create and varies from the infrastruc-ture they can use. As for the computer platform, they can make the choice among mainframe, UNIX based Work Station, PC or so. And for communication platform, Satellite, ISDN, public phone line, internet and so on. Quality of the data especially that of image data they want to transfer also varies from their needs. The quality required by radiologists is not that of internists or surgeons, that of pathologists or dermatologists must be considered on another tables. As for the technical aspect, if one choose the slower telecom environment, data compression must be inevitable for practical use, but there exists no need to pay attention for data size if they can use the fast-enough telecom modalities. Another important factors which affect the modarities and qualities of telemedicine are legal and social requirements. Considering all of them, telemedicines performing now in Japan will be presented and some demonstration will be shown if possible. /* --------------------------------------------------------------------- */ Abstr. no 41 - COST BENEFIT ANALYSIS OF TELEMEDICINE, HEALTHNET Bill McCaughan, Dr. & Sherald A. Ramirez, Texas Tech University Health Sciences Center HealthNet, 3601 4th St., Lubbock, Texas, USA 79430 TTUHSC HealthNet is an organization of the Texas Tech University Health Sciences Center in Lubbock, Texas, USA, committed to improving health care for citizens living in remote or rural areas through the use of telemedicine. Building on the success of the Texas Tech MEDNET Demonstration Project, telemedicine technology is used for two-way interactive guidance and consultations between family practice physicians in Alpine, Texas, and specialists at the TTUHSC in Lubbock, Texas. During the demonstration project period, an independent accounting firm analyzed the cost of three remote consultations. Using telemedicine, an average savings of U.S. $1,500 per patient was attained. The independent cost analysis report will be presented as well as the results of the demonstration project final report, including total amount and types of remote consultations performed. The HealthNet Rural Telemedicine System is used to facilitate medical examination for inmates of the Clements Correctional Facility, approximately 75 miles from the Health Sciences Center. Cost savings realized by the elimination of inmate transport and personnel cost savings will be presented. Current coordination with the U.S. Health Care Financing Administration is in progress, to address reimbursement issues concerning payment for telemedicine consultation. Strategies for reimbursement will be presented. /* --------------------------------------------------------------------- */ Abstr. no 42 - STATIC VERSUS DYNAMIC IMAGING IN TELEPATHOLOGY Ronald S. Weinstein, MD, Department of Pathology, University of Arizona, College of Medicine, Tucson, Arizona, U.S.A. Whereas dynamic (real time) telepathology imaging requires the use of broadband telecommunications channels, static telepathology imaging can be carried out over conventional telephone lines. This reduces costs and markedly increases access to the technology. Disadvantages of static imaging, compared with dynamic imaging, include the relatively small number of images that are conveniently examined per case with static imaging systems, and the constraints placed on the consulting pathologist who must depend on others to select microscopic fields. Several studies have measured viewing times per case and diagnostic accuracy. Results indicate that viewing times are increased five-fold or more with static imaging, compared with real-time dynamic imaging. Combining slow-scan real time imaging, for specimen orientation, with static imaging may not improve viewing times over those obtained with static imaging alone. Diagnostic accuracy may be similar with static and dynamic imaging. Static imaging requires the presence of a more highly-trained system operator at the transmit site. /* --------------------------------------------------------------------- */ Abstr. no 43 - TECHNOLOGY ASSESSMENT OF MEDICAL VIDEO IMAGES Elizabeth A. Krupinski, Ph.D., University of Arizona, Tucson, AZ, U.S.A. A major issue which must be addressed when considering the requirements for a telemedicine system is the quality of the video image that must be viewed by the physician. Image quality assessment should take three factors into account: image fidelity, informativeness and aesthetics. Purely physical methods such as measuring the signal-to-noise characteristics of a video monitor can be used to assess image fidelity; but well-controlled observer performance studies must be conducted to assess the ways in which image informativeness and aesthetics influence diagnostic accuracy. Technology assessment should also take various human factors issues into account: user interface assessment, differences in viewing time for conventional vs video display systems, and so on. Preliminary results assessing some important aspects of displaying and viewing video medical images for the purpose of reaching a diagnostic decision (such as resolution requirements, colour requirements, display interface and use of image processing tools) will be presented. A brief introduction to modelling and assessing user interface to medical video display systems will also be outlined. /* --------------------------------------------------------------------- */ Abstr. no 44 - NEUROMUSCULAR DIAGNOSIS ACROSS THE ATLANTIC OCEAN Sigurd Lindal 1), Irene Lund 1), Eivind Rinde 2), Ivar Nordrum 1), Tor J. Eide 1), Mahlon C. Stacy 3), and Andrew G. Engel 4) 1) Dept. of Pathology and Dept. of Telemedicine, University Hospital of Tromsx. 2) Norwegian Telecom Research, Tromsx. 3) Dept. Medical Sciences, Mayo Clinic, Rochester, MN USA 4) Department of Neurology, Mayo Clinic, Rochester, MN USA The aim of the present study was to evaluate the possibility of using video frame grabbing and telecommunication techniques for diagnostic purposes in medicine. Electron-microscopic images from muscle specimens from 10 patients with different muscle diseases, were sent file transfer in Internet from Tromsx University Hospital, Norway, to Mayo Clinic, Rochester, USA. All together 117 images were transferred to Mayo Clinic. After each transference, a telefax with clinical information, anonymous identification and number of images was sent. The same electron micrographs and light microscopic sections were sent by mail for later comparison. The quality of the images was excellent, the method is fast and the technique is not expensive. The technique can easily be used for diagnostic purposes between hospitals. /* --------------------------------------------------------------------- */ Abstr. no 45 - VISUAL TELECOMMUNICATION IN ROUTINARY DIAGNOSTIC PATHOLOGY - RESULTS OF ONE YEAR EXPERIENCE K. Kayser 1), M. Drlicek 2) 1)Department of Pathology, Thoraxklinik, D-6900 Heidelberg, Germany 2)Institute of Pathology, Klinikum Baumgartner Hvhe, A-1145 Vienna, Austria Expert consultation and panel board discussion between the Department of Pathology, Thoraxklinik, Heidelberg and the Institute of Pathology, Klinikum Baumgartner Hvhe, Vienna using visual telecommunication were started January 1992. Histological images are transferred with a commercially available computerized modem (VP2000) connected to a normal telephone line. The system is in use for request of diagnostic assistance in difficult intraoperative frozen sections, pulmonary diseases and tumors, paraffin embedded and conventionally or immunhistochemically stained. Images of more than 100 cases have already been transmitted and discussed. Delay of intraoperative sections due to telecommunication accounts to 10 minutes, expert or panel discussions usually last 10-15 minutes. Telepathology is comparable or even superior to conventional consultation procedures in fundamental diagnostic assistance. /* --------------------------------------------------------------------- */ Abstr. no 46 - DESCRIPTIVE ANALYSIS OF LIGHT MICROSCOPY IMAGES IN THE FIELD OF ANATOMIC PATHOLOGY Al M. Elsayed, M.D., Norman J. Carr, MRCPath*, and James M. Monihan, M.D., from Armed Forces Institute of Pathology, Washington, D.C., USA and *Royal Air Force Institute of Pathology and Tropical Medicine, Halton, UK. In the field of anatomic pathology the pathologist utilized a variety of data to produce a diagnosis. Of paramount importance is the visual image as seen through a light microscope. We have attempted to describe this image in both quantitative and qualitative terms. A comprehensive understanding of the inherent characteristics of this image is mandatory if a new medium, such as Telemedicine, is to be introduced into the conventional specimen-microscope- pathologist continuum. The microscopic field of a compound microscope is a circular virtual image appearing to be 80cm in diameter and projected 100cm from the observer. This results in a centered field of view measuring 44 degrees in visual arc. The number of picture elements (pixels) resolvable by the human eye in this virtual image is limited primarily by the numeric aperture (NA) of the objective lens and secondarily by the visual acuity of the observer. For a typical 10x objective with NA=0.30, approximately 1790 pixels are resolvable. The number of simultaneously viewable colours is determined by both the intensity of light used and the eye's ability for colon separation in the blue, red and green colon bands. /* --------------------------------------------------------------------- */ Abstr. no 47 - TECHNICAL REQUIREMENTS OF TELEPATHOLOGY DEVICES IN THE FIELD OF ANATOMIC PATHOLOGY Al M. Elsayed, M.D., James M. Monihan, M.D., and Norman J. Carr, MRCPath* from Armed Forces Institute of Pathology, Washington, D.C., USA and *Royal Air Force Institute of Pathology and Tropical Medicine, Halton, UK. Acquisition, transmittal and display of anatomic pathology images are pivotal for the performance of a Telepathology consultation service. The goal of such a service is to enable the pathologist at the viewing site to render an accurate diagnosis. In a perfect system, every effort would be made to deliver an image equal, or preferably superior to, that viewed directly through a light microscope. Image acquisition: Cameras with a resolution matched to that available in the image projected by the microscope, about 2k x 2k picture elements (pixels) suffice. Such cameras are available. Transmission: Techniques will allow real-time viewing if wide bandwidth links are used. However, sequential viewing of a patch of images sent previously by the contributing pathologist is far more economical and meets routine surgical requirements. Display: A 50cm x 50cm display centered in front of the viewer at a distance of 65cm provides the same field of view as a microscope. At 65cm distance a 100% visually efficient (VE) viewer, (i.e. an individual with a 6/6 visual acuity), can resolve 2600 different points across a 50cm field. The best available display can only provide 2000 points. This represents about 89% VE, equivalent to a visual acuity of 6/9.8. Images: With 24 bit colon, true colon rendition is achieved. The challenge is the image size (12 MB). This image size demands expensive frame buffers and powerful image processors with a wide image bus. Processing: Focusing through a stained tissue section while capturing images at 0.75 micron intervals allows a stack of images to be produced, permitting the viewer to focus through the section. This process is easy to achieve through modest programming effort. Conclusion: It is currently possible to build a Telepathology system that approaches conventional anatomic pathology image quality. At the AFIP we are currently developing this system. /* --------------------------------------------------------------------- */ Abstr. no 48 - TELEMICROSCOPY FOR TELEPATHOLOGY - TWO APPROACHES P. Schwarzmann, Inst. f|r Physikalische Elektronik, (IPE), Pfaffenwaldring 47, D 7000 Stuttgart 80, Germany The IPE of the University of Stuttgart develops and realizes installations for Telemicroscopy dedicated to Telepathology. To promote this new field the IPE installs two demonstrators for Telemicroscopy following two different concepts concerning the telecommunication link. This is to gain experience for the advantages and disadvantages for both solutions: a) A system relying on the highest level of available telecommunication links offered as a standard by the PTT's. This is the system ZELLKOM applying the teleconference network in Germany. This concept offers a nearly perfect illusion for the remote partner (pathologist) to be present at the microscopes site. This solution asks for a broadband network which is expensive and which may be available only at selected locations. b) A system relying on the future world standard for telephone service nets (ISDN). This solution imposes restrictions concerning online illusion which in parts may be overcome by datacompression, datareduction and operator optimized system operation. Instead this solution offers the cheap and easy worldwide connection between the computer controlled microscopes of the clients and the Telepathology workstations of the servers. At the IPE solution a) is in operation already and solution b) will become operational in 1993. Both concepts are tested under routine conditions for pathology and scientific applications. /* --------------------------------------------------------------------- */ Abstr. no 49 - TELERADIOLOGY IN SWEDEN Sven Laurin, MD, University of Lund, Sweden Teleradiology development in Sweden started in 1981. Using a TV-camera and analog/digital technique various emergency radiologic images were transmitted between Landskrona and Helsingborg. This technique is now commercially available from many vendors and is used in several installations (e.g. Visby, Vstersund, Uppsala). Using scanner technique (Vrebro, Mjxlby) higher spatial and contrast resolution is achieved. Video-conference technique has been successfully tested in Lund for teleradiology purposes connecting with e.g. Karlskrona, Tromsx and Heidelberg. Direct digital transfer of CT images in 1988 was successfully tested between Ystad and Lund. A network is now being installed between the 5 hospitals in Malmxhus County. Special interfaces will connect all the different image modalities to the network. This will allow direct transfer of all types of digital images using the Dicom format. At present, image transfer is slow (64kbit/s) but upgradable to 2 Mbit/s. Results: Since TV-camera images have limited spatial and contrast resolution their optimal use is for digital images, e.g. CT and MR. Scanned images have the dynamic range and spatial resolution of film, permitting diagnostic quality of all types of images. Videoconference uses a large bandwidth, yet spatial and contrast resolution is low. This is compensated for real-time imaging which allows instantaneous manipulation of the image, hence zoom and brightness can be immediately adjusted. For clinical conferencing, videoconference is unsurpassed. Direct digital transfer preserves all image information but a substantial investment in a network is necessary. Various types of teleradiology technique are available on the market today. To integrate teleradiology into clinical practice both technical and educational questions must be considered. Abstr. no 50 - OSI/ODP CONCEPTS FOR HYPERMEDIA COOPERATIVE WORK APPLICATION TO TELE-RADIOLOGY AND TELE-CARDIOLOGY P. Jensch, A. Hewett, A. Barth*, Fachbereich Informatik, C.v.O Universitdt Oldenburg, Postfach 2503, D-W2900 Oldenburg, Germany. *OFFIS, Oldenburger Forschungs- und Entwicklungsinstitut f|r Informatikwerkzeuge und Systeme, Westerstr. 10-12, D-W2900 Oldenburg, Germany Cooperative working with hypermedia documents has applications in many areas where it is necessary for geographically dispersed people to jointly and interactively converse over a common information pool. Scenarios within the medical sphere include: remote consultation, remote diagnosis and wide area conferencing. In this paper we outline a cooperative working system for hypermedia documents. With this background we examine the OSI/ODP concepts necessary when realizing such a system. In particular, we explain the document structuring facilities in light of ODA, SGML/Hy/Time and the forthcoming IPI standards to express user needs in viewing and handling documents for specific user roles. The structuring concept is object-oriented in order to support bridge functions for interfaces to specific standards by a data interchange facility -to allow an internal data representationeven in cooperative working environments. Applications for tele-radiology and tele-cardiology illustrate the advantages of different types of object bindings for hypermedia documents expressed by object-oriented inheritance and association. /* --------------------------------------------------------------------- */ Abstr. no 51 - INTERNATIONAL REMOTE EXPERT CONSULTATION IN RADIOLOGY USING BROADBAND COMMUNICATION Marlene Gerneth, Frank-Reinhard Bartsch, Rudolf Schosser, University of Heidelberg, Dept. Exp. Surgery Im Neuenheimer Feld 347, D-6900 Heidelberg, Germany Remote Expert Consultation has been investigated on a European scale as a tool for diagnostic support in radiology. Consultation situations between requestant and expert are represented by three different communication modes: batch (normal scenario), interactive (emergency scenario), and mixed mode (teaching scenario). Eight university hospitals in seven countries have been interconnected via broadband networks. Advanced telecommunication services such as videoconference (VC) and digital image communication (DIC) are employed. Utilization of commercial VC services between 2 and 140 Mbit/s has been evaluated between radiology departments in Berlin, Geneva, Heidelberg, Lund, and Tromsx. The necessary flexibility in scheduling consultations was ensured by self-dialled connections between all participating sites. Commercially available VC equipment, supplemented by customized document transmission units, was used. Reporting on more than 350 cases revealed no degradation for digitally recorded images, while conventional radiographs with very subtle radiological signs proved to be difficult to report. In total, the participating radiologists judged VC a useful tool. For DIC, Macintosh based workstations have been installed, connecting to PACS or imaging modalities. To allow short transmission and response times for the voluminous data files, public broadband networks are employed to interconnect the participating sites (the above and Barcelona, Florence, and Montpellier). To support consultation, special software modules have been developed: RECPHONE (Univ. Patras) for interactive exchange of text and image files, OSIRIS (Univ. Geneva) for viewing and manipulating radiological images, both relying upon PAPYRUS (Univ. Geneva) as common medical image file format, and finally HERMES (TeliaResearch, Malmv) for synchronizing two remote workstations. DIC can be expected to become increasingly accepted as computers and digitally recorded and stored images become commonplace. /* --------------------------------------------------------------------- */ Abstr. no 52 - GENERICS OF A REMOTE CONSULTATION SYSTEM FOR RADIOLOGY Marlene Gerneth, Frank-Reinhard Bartsch, Rudolf Schosser University of Heidelberg, Dept. Exp. Surgery Im Neuenheimer Feld 347, D-6900 Heidelberg, Germany Increasing specialization in medicine and the resulting geographic scattering of experts lead to a growing need for consultations, particularly remote consultations. Modern telecommunication technologies offer the appropriate means to support such communication. In the TELEMED project (sponsored by the EC as project no R1086), videoconferencing (VC) and digital image communication (DIC) have been investigated regarding their usability for remote expert consultation in radiology. For both systems, we could determine advantages and disadvantages: VC: pro: familiar way of handling radiological images (films), interpersonal face-to-face communication; con slight reduction in image quality DIC: pro: no information loss; con: higher level of abstraction for image handling and communication by computer. From these experiences, we deduce the following architectural concept of an optimal communication system for remote consultations in radiology, providing different communication means in one media-integrating (tele)communication system. As necessary components, such a system should comprise interpersonal communication facilities (audio and video communication) and still image transmission (via document camera) as well as digital communication from workstation to workstation, including both images and text documents. The system should be integrated (into one piece of equipment as well as into the environment of a radiological department), modular (adaptable to different communication needs by combination of individual components), flexible (supporting various band-widths according to the actual communication needs), and compatible (providing standardized interfaces to other communication systems, radiological modalities, etc.). Economic considerations as well as the future potential for reduplication and evolution into routine usage should stimulate the development of such communication systems. /* --------------------------------------------------------------------- */ Abstr. no 53 - TELERADIOLOGY IN NORTHERN NORWAY. THE "TMS" PROJECT Jan Stxrmer, Rxntgenavdelingen, University Hospital, 9038 Tromsx Troms Military Hospital (TMS) situated 270 km from RiTx (University Hospital of Tromsx) has a conventional X-ray unit staffed with 1 radiographer. Approximately 20-30 patients are examined on all regular workdays. The majority of patients are civilians referred by local general practitioners. Until fall 1992 a specialist in radiology from RiTx had a one day reading session for a one week production in this remote hospital (travelling time approx. 5 hours). The teleradiology project taken into regular service in the beginning of September 1992 actually permits the reading to be done at the University clinic on an every day basis. Software for scanning analogue X-ray images on TMS, transmission on a 64 kbyte telephone line, and a multiple screen radiological workstation has been developed by the Norwegian Telecommunication Research Organisation in collaboration with the medical staff of the radiological Department of RiTx. We are presenting a status of this project which has been in uninterrupted service for 7 months with approximately 2000 patients. We will also present demographic clinical and financial data relative to the performed examinations. /* --------------------------------------------------------------------- */ Abstr. no 54 - THE ACR-NEMA STANDARD FOR MEDICAL IMAGE COMMUNICATION Joseph N. Gitlin, Professor, The Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A. In 1982, the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) formed a Committee to develop standards for communications between medical imaging devices. Versions 1.0 and 2.0 published in 1985 and 1988 respectively, were concerned with point-to-point image transmission, while Version 3.0, also referred to as DICOM, provides specifications for network connections. The DICOM Standard conforms to the International Standards Organization (ISO) reference model for network communications, maintains compatibility with the earlier point-to-point Versions 1. and 2., and incorporates the concept of object-oriented design. This version of the ACR-NEMA Standard will be completed in September 1993 and demonstrated at the annual meeting of the Radiological Society of North America (RSNA) in Chicago on November 28the through December 3rd. The emphasis of the presentation will be on the format of data messages that cross the interface. In addition, the ISO reference model for communications interfaces will be described and the fundamentals of object-oriented analysis will be introduced as background information for understanding the Standard. /* --------------------------------------------------------------------- */ Abstr. no 55 - MEXICAN CENTER FOR TV-CONTINUING MEDICAL EDUCATION: AN EXPERIENCE ON TELEMEDICINE Dr. Luis Torregrosa Ferraez, Dra.Ma.Del Carmen Ruiz Alcocer, Hospital Infantil de Mixico Federico Gsmez, Cemesatel. Dr. Marques No. 162, Col.Doctores, Del. Cuauhtimoc, CP. 06720 Mixico, Distrito Federal, Mixico. Mexico, as a developing country has rural population. Such population receives medical attention by doctors whose Continuing Medical Education is still a big problem. Because of that, and having the experience of the clinical- pathological sessions, we started at Hospital Infantil de Mixico Federico Gsmez a TV-health program on September, 1985. OBJECTIVE. To operate a Continuing Medical Education Program covering Mexico through Mexican Communications Satellites, called "Morelos System". METHOD. The program operates as live transmissions from the Hospital Infantil de Mexico to 220 reception centers all over the country. The program includes topics in Pediatrics, Surgery, Internal Medicine and Gynecology and Obstetrics, focusing on epidemiology, prevention and treatment, presented by the National Health Institutes of Mexico. It is possible to have phone communication during the live transmissions between the speakers and the teleaudience. RESULTS AND CONCLUSIONS. Our teleaudience increased from 17 reception centers in 1985, to 220 in 1992. We began to evaluate the impact of the program in 1992 and the reported results were "positive": doctors had a good opinion about the program format and most of them considered the topics presented as "useful" for their professional practice. We conclude that our program must be continued adding a more thorough evaluation. /* --------------------------------------------------------------------- */ Abstr. no 56 - REMOTE TEACHING IN THE MEDICAL CURRICULUM IN CANADA The Application of Telecommunications to Distance Health Education Max House, MD, FRCPC, Memorial University of Newfoundland, St. John's Newfoundland, A1B 3V6, Canada While the majority of physicians and other health professionals live in urban locations, a significant proportion live and work in non-urban, remote and often isolated areas. The provision of continuing medical education (CME) and training programmes for these individuals has always been a challenge. Since the early 1950s, when organized continuing medical education was recognized as an important part of the medical education continuum, a number of technologies and systems have been used to deliver courses at a distance. In some centres the term telemedicine was used to include distance education, and in Canada the majority of telemedicine projects have emphasized the importance of telecommunications in this field. In the United States in the early and mid-70s the WAMI (Washington, Alaska, Montana and Idaho) project of the University of Washington in Seattle was mainly an educational project as was Memorial University of Newfoundland's which emphasized CME. These projects used respectively the US Applications' Technology Satellites and the joint US/Canadian Hermes Satellite. A few ground-based systems began three decades ago in the US and the majority of interactive systems are currently using ground-based audio systems. Memorial University which has been a leader in the field, has a province-wide Teleconference System (TCS) which offers a wide variety of programmes for all health workers. Memorial has coordinated a Canada-wide teleconference network involving all medical schools, has carried out an inter-national satellite project involving East Africa and the West Indies, and is at present participating in HealthNet, an international low-orbit satellite project of SatelLife. Internationally, CME programmes are using direct broadcast television by satellite, cable networks, and compressed video on digitized telephone networks. In North America ground-based audio teleconference systems sometimes supported by telewriters are still the prime delivery method. Given the ever increasing costs of travel and the increasing demand for continuing health education, it will be essential to use information technology and telecommunications to satisfy these important needs of the health profession. /* --------------------------------------------------------------------- */ Abstr. no 57 - DISTANCE TEACHING IN DECENTRALIZED NURSING EDUCATION Arnfinn Andersen, Mari Wolff Skaalvik , Tromsx College of Health Care Education, Tromsx, Norway Background A great lack of qualified nurses in certain areas of Troms county was the background for establishing decentralized nursing education (DNE) at Tromsx College of Health Care Education in 1990. This is the first DNE in Norway. Organization The structure for DNE education is as for the ordinary nursing education and gives a competence as a registered nurse. The theoretical part of the study is organized as week, weekend and day-sessions. The students are divided into groups of 3-8 students belonging to a geographical area. The week and weekend sessions take place in Tromsx while the day-sessions take place in the students home-community. The practical studies are connected to the primary health care in the home-communities except three months of practical studies in hospital. Experiences DNE requires special adjustment of the curriculum and pedagogic in order to accommodate the students and the goal and quality of the education. We made an early experience of the need to structure the curriculum in order to decentralize a greater part of the education to local sessions and individual studies under supervision. To strengthen the contact between the college and the students, we have employed nursing teachers living in the district of Troms. In order to fulfil this we have also taken into use video-supported teaching and telecommunications. Distance teaching To strengthen the contact between students and the College there have been established 11 conference rooms strategically situated as to where the students live. This has been done in cooperation with the communities involved, and the Tele company. These conference rooms are equipped with TV, video, loudspeaking telephone and telefax. There have been developed learning sequences on videotapes which the students use as means of learning and discussion. There have also been developed studying tasks, and after each video session the students can communicate with their teacher for supervision by using the tele-communications. This equipment is important means in the supervision to the students working with specific papers and exams. CONCLUSION The component of distance teaching in the nursing education is based on simple and fairly cheap technical aids as video, loudspeaking phone and telefax. Combined with varied pedagogic methods the model for education has proved to be very successful. Our goal for the future is to develop the model with the use of data-communication. /* --------------------------------------------------------------------- */ Abstr. no 58 - STRENGTHENING THE EDUCATIONAL OUTCOME OF REMOTE MEDICAL CONSULTATIONS THROUGH COMPUTER-BASED EDUCATIONAL APPLICATIONS Svein-Ivar Lillehaug, Institute of Community Medicine, University of Tromsx, N-9037 Tromsx, Norway. Sigmund Akselsen, Norwegian Telecom Research, P.O.Box 1156, N-9001 Tromsx, Norway In 1988, Norwegian Telecom Research (NTR), in cooperation with the University Hospital in Tromsx (UHT), started a project on telemedicine in North Norway. An objective is to use telemedicine to provide equal health care services to each individual in Norway, regardless of geography or economic variation in the population. Applications such as tele-endoscopy, remote diagnosis of skin diseases and remote echocardiology have been developed and tested. Most of the applications can be defined as remote consultations where the specialist is located at UHT while the practitioner and the patient are located at a remote hospital or health institution. The projects's success has resulted in a demand for this type of services which in turn will result in an increased load on the specialists and their departments. One way to deal with this increasing demand can be to provide the different remote applications with additional tools that offer the practitioner an efficient learning environment. In this way the practitioner can reach a level of independence more quickly. Computer-Based educational applications have the potential to facilitate both learning and assistance during a consultation. By integrating advising facilities into a learning environment, both aspects can be addressed by the same application thus relieving some of the burden on the specialist. The educational outcome of the remote consultation will be discussed from the perspective of an educational theory to give an understanding of how teaching and learning is performed within the different disciplines. Then, the focus is put on computer-based functionalities that can increase the educational outcome in remote consultations and, at the same time, serve as advisors for the practitioner. Examples are given within remote echocardiology. /* --------------------------------------------------------------------- */ Abstr. no 59 - USING TELEMEDICINE FOR DISTANCE LEARNING Bill McCaughan, Dr. & Sherald A. Ramirez, Texas Tech University Health Sciences Center HealthNet, 3601 4th St., Lubbock, Texas, USA 79430 Telemedicine enables over 500 physicians, approximately 700 nurses and approximately 800 allied health professionals to receive accredited continuing education programs via the Rural Health Satellite Network of TTUHSC HealthNet and the Texas Tech University Health Sciences Center. These programs are designed to meet the needs of family practice physicians, nursing personnel and various allied health professionals in remote and rural areas of West Texas and Eastern New Mexico. Based on bi-annual needs assessment surveys of all participants, specialists and content experts present programs applicable to patient care in many disciplines required for general practice in rural or remote communities. Each program is evaluated by participants to assess applicability of the material presented to participants' practice sitting. In a summary report of the first two years of the programming, 68 percent of the physicians who viewed the programs stated that they used the information presented at least once a week to treat patients and 58 percent of allied health professional used the information at least once a week to care for patients. Participants respond that information from programs about emergency care, nursing care, pulmonary and cardiac topics, and diabetes was used in patient care most often. Final results of this summary report will be presented, as well as the future activities of the Rural Health Satellite Network. /* --------------------------------------------------------------------- */ Abstr. no 60 - IMPROVING RURAL HEALTH CARE James E. Dalen, MD, The University of Arizona, College of Medicine, Tucson, Arizona 85724 U.S.A. A shortage of primary care physicians in rural areas is a significant problem in the U.S. and in many other nations. Physicians may prefer to practice in urban or suburban areas rather than in rural areas for personal or professional reasons. Personal reasons include access to educational and cultural activities in urban areas. Professional reasons include a feeling of isolation due to the lack of specialists and state-of-the-art facilities in rural areas. Telemedicine has the potential to increase the level and quality of specialized services available to underserved areas, and to decrease the sense of professional isolation by physicians in rural areas. On-Line access to consultants in pathology and radiology are readily available by telemedicine. On-line access to specialists in medicine, psychiatry, paediatrics, surgery, and obstetrics and gynaecology would further assist rural physicians and could serve as a focal point for ongoing continuing medical education. Several proof-of-concept telemedicine demonstrations are underway at The University of Arizona. /* --------------------------------------------------------------------- */ Abstr. no 61 - OPPORTUNITIES FOR TELEMEDICINE IN NEPAL Sundar M. Dixit, MD, Katmandu, Nepal Nepal is an unique landlocked country with diverse biophysical and social structures. Diversified living in terms of geography, culture and climate surprisingly symbolises and unity which is based upon a long history of tolerance and mutual confidence of the people in one another.Modern development began with dawn of democracy in early 1950's. Planned development started with the first elected Government in 1958 which lasted a mere 20 month after which a dark period of thirty years of autocratic rule supervened. During this period developmental activities stagnated. It is only in the last two years that an elected Government has again come into power and the institutionalisation of development has again started. The reestablishment of democracy has been brought about with tremendous sacrifices by the Nepalese population. Improper health policies by the autocratic Governments had left the health institutions in shambles to the extent that specialised health manpower was totally neglected while at the same time cheap popularity was sought to be gained by opening several health institutions. The result was the population was bluffed into thinking that health services were on the way to improvement where as in reality it was just the opposite. The new health policy has clearly expressed its priorities to make available health services at village level with improvements on specialised referral health services delivery mechanism along with due preferences on noncommunicable diseases like cancer control. Specialised health services development requires high level of technological support and management skill in a country which has just opened its windows of opportunities. The Telecommunication facility still enjoys Government monopoly but has a best call completion rate of more than 50 percent from abroad - best situation in SAARC Region. More than 86 % of the network is digitalised and new communication Act this year will reduce government monopoly and will promote its role on social services. This will be further strengthened by National Televisions Satellite networking and privatisation schemes are going to be initiated very soon. B.P. Koirala Memorial Cancer Hospital will be an apical institution for Cancer Control. The hospital itself is being built with a Chinese Grant and should be completed by the end of 1995. However, the National Cancer Control Project which will be teamed up with the hospital will be operating as soon as possible and for this the present hospital construction committee will be responsible and for this the committee is looking for bilateral assistance from any friendly donor country to work on a long term basis with the hospital in future. The best complement to the transfer of technological knowhow and strengthening of Nepalese technical capabilities can be achieved via Telemedicine a system of innovation justifies in several ways. Such system will be a gift to the new democracies which hastens the pace of development especially in countries where transport facilities are difficult and in same cases virtually non existent. Telemedicine will reverse the present day situation where expert opinion for people living in remote areas is non existent. And even in Urhan areas with hospital facilities patient's relatives will not have to carry Pathological Slides to various developed countries for final opinion once Telemedicine comes to be a part of hospitals in underdeveloped countries. For Nepal we visualise great potentialities through the medium of Telemedicine not only for health but for many other developmental activities. What seems today to be a very sophisticated area of development would in Five to Ten years be commonplace, we are sure, and this would be to the good of the whole world for the future. Telemedicine and related activities are the future of the world. /* --------------------------------------------------------------------- */ Abstr. no 62 - "TELEMEDICINE - A SOLUTION TO THE PROBLEM OF MALDISTRIBUTION OF HEALTH CARE SERVICES - A 25 YEAR PERSPECTIVE" Jay H. Sanders, MD, Professor of Medicine, Director, Telemedicine Center, Medical College of Georgia Despite dramatic advances in our ability to treat the medical needs of our population, our capability of delivering that care has remained in a "horse and buggy" era. Frustratingly, multiple studies have documented that as a result of geographic and socio-economic isolation millions of people have been disenfranchised from the comprehensive health services they require. Fragmented access, inconsistent quality, excess costs, loss of continuity and ineffective continuing medical education have characterized the elements of our existing system. As a result alternative health care delivery systems have had to be explored. Telemedicine, which utilizes advanced interactive telecommunication technology to provide a physician at one location the ability to examine a patient at a remote site as if that patient were actually in the physician's office, is one such alternative. The results of telemedicine applications over the past 25 years in the private patient sector, mental health care facilities, correctional institutions, nursing homes and rural hospitals have demonstrated the ease of patient/physician acceptance, improved access, enhanced quality, and a reduction in the cost. /* --------------------------------------------------------------------- */ Abstr. no 63 - TELEMEDICINE: ETHICS, TECHNOLOGY AND ECONOMICS Jane Preston, MD, FAPA, Telemedical Interactive Consultative Services, Inc., c/o MCC, P.O. 200195 Austin, Texas 78720 Ethics may be defined as respectful and gentle management of the intimacy space that bonds patient and caretaker. In the past 85 years technology has produced vast differences in travel, and medical treatment. These differences have changed what is ethically expected of a physician. Telemedicine also adds new dimensions to ethical management of patient's healthcare. Telemedicine can quickly establish an intimacy space between doctor and patient, even between differing cultures, but how is the quality of that intimacy to be managed? Also, what are the ethics and economics of a dispersal system that inherently is capable of near ubiquity. The Texas Telemedicine Project has focused on the ethical imperative of universal access to personal care in the United States, and on economic factors to make it possible. A.Technology, distance, and ethical responses B.The Texas Telemedicine Project C.Projections /* --------------------------------------------------------------------- */ Abstr. no 64 - MEASURING BENEFITS OF TELECOMMUNICATIONS IN HEALTH CARE RESULTS OF A 1992 NATIONAL STUDY OF THE US Mark K. Schneider, Telecommunications. Arthur D. Little, Inc., 20 Acorm Park, Cambridge, MA 02140-2390, U.S.A. This presentation will discuss the results and methodology of a 1992 study of the impact of telecommunications on US health care. The study focused on applications in four basic areas: * moving patient clinical data * moving patient financial data * moving material management data * moving video images Research was done by gathering other primary research data and the results from pilot tests and beta sites. This was sorted, screened, analyzed and loaded into an economic model. Results from the model (cost reductions) were combined with the qualitative data (benefits in health care access and health care quality) in the draft report. The draft was reviewed by representatives of key constituencies (physicians, insurers, regulators, consumers) before going to final production. Key findings of the study include potential cost reductions of 36 billion dollars from more proliferated use of telecommunications and significant enhancements in quality and access. The presentation will describe the challenges, limitations and advantages of the study approach as well as provide more detail on the applications and results. /* --------------------------------------------------------------------- */ Abstr. no 65 - QUALITY ASSURANCE AND TELEMEDICINE Kirsten Staehr Johansen, Quality of Care and Technologies Programme, World Health Organization, Regional Office for Europe, 8 Scherfigsvej, DK 2100 Copenhagen Appropriate information technology applied to health care is a top priority for research, design and implementation in most European WHO Member States as expressed in a specific target of the common HFA-policy and strategy (Target 35 - Health Information Support) (I). It is considered an indispensable tool for quality development in health care. Definition of quality in health care and establishment of specific policies and strategies are prerequisites to understand and implement quality and quality development mechanisms accordingly in medicine (1-6). Through appropriate use of information systems, it is possible to collect, transfer, analyze and compare key components and variables in a systematic fashion (3-4). Quality assurance relies on the availability of accurate and consistent quantitative information. Modern information technology has provided us with an increasingly powerful tool for efficient handling of large amounts of data on individual cases, collecting and aggregating this into patterns and meeting the requirements of multiple users, including an analysis of quality indicators of health care services (3-7). The use of information systems in health care has until recently been confined mainly to administration and planning, and has primarily been developed for accounting and budgetary purposes. However, this situation is rapidly changing. The Regional Office for Europe of the World Health Organization (WHO/EURO) has developed and tested three pilot quality assurance and development programmes: WHOCARE (nosocomial surgical wound infection), DiabCare (diabetes management) and ORATEL (oral health care), in collaboration with the respective professional associations. The software for oral health includes both a retrospective and a proactive quality assurance component, in addition to management facilities. The experience obtained from these activities has demonstrated that the approach is useful and is currently being introduced into other areas of medicine (5-7). These computerized information systems have been developed with the main objective of improving the outcome of health care; however, with the evolution of telemedicine, other aspects will certainly be included in future programmes. /* --------------------------------------------------------------------- */ Abstr. no 66 - STATUS OF TELEPATHOLOGY WORLDWIDE: PLANS FOR IMPLEMENTATION AND TESTING OF SYSTEMS Ronald S. Weinstein, MD, Department of Pathology, University of Arizona College of Medicine, Tucson, Arizona, USA Telepathology is defined as the practice of pathology at a distance, be visualizing an image on a monitor rather than viewing a specimen through a microscope. Although the field of telepathology is in its infancy, it is already apparent that the technology may: aid in distributing anatomic pathology services to underserved areas; improve access to subspecialty pathology services; play a role in quality control and assurance programs; and upgrade educational programs. Currently, significant telepathology (and telemedicine) programs are being implemented in many countries including Norway, the United States, Sweden, Germany, France, Greece, and Japan. In order to support the further development and implementation of telemedicine programs, two new organizations have been chartered. The International Academy of Telemedicine will: provide educational programs for telephysicians and others; develop industry standards; publish newsletters and journals; and work on the coordination of various telemedicine projects. The International Telemedicine Network will provide backbone communications channels for providers of telemedicine services. /* --------------------------------------------------------------------- */ Abstr. no 67 - CURRENT AND FUTURE ASPECTS OF TELEMEDICINE IN THE EUROPEAN COMMUNITY (EC) Thomas J. Sommer, CEC, DG XIII C3 AIM, 200 rue de la Loi, B-1049 Brussels, Belgium Apart of ongoing national projects, a necessity for a European scale action, driven by the users, has been identified. As a result, an EC R&D action AIM (Advanced Informatics in Medicine) has been created in 1988 with the objective to apply information and telecommunication technologies to medicine and health care. Telemedicine (TM) represents one important part of the scope of AIM. The ongoing 1991-94 AIM phase with a budget of 97 million ECU emphasizes building of prototypes and pilot applications. To ensure synergy, the TM projects meet 5 times a year in the framework of a concertation mechanism grouped in a Project Line (PL). The objective is to work towards a framework for TM applications, likely a set of open platforms. A common working scheme has been adopted. The PL identified a number of subjects of common interest, like cost/benefit analysis, TM services etc. to be handled in dedicated workshops. An overall strategy for the introduction of TM is needed. An impetus and consensus can be reached only on European level. The implementation, however, should be performed nationally, according to the principle of subsidiarity but, with the highest possible compatibility transnationally. /* --------------------------------------------------------------------- */ Abstr. no 68 - MEDICAL COMMUNICATIONS IN THE 21ST CENTURY: A NEW GLOBAL OUTLOOK Omar M. Lattouf, M.D., Ph.D. Chairman, Elizabeth C. Davison, Deputy Director, International Medical Institute, 315 Boulevard, NE, Suite 224, Atlanta, Georgia, 30312, USA In April 1992 the International Medical Institute held an International Conference on the need, feasibility, and acceptance of telemedical application in the practice and delivery of medicine. Physicians, administrators, businessmen, technology, information systems and communication experts from over a dozen countries participated in a series of presentations and round table discussions on telemedicine and its national and international implications. Conference conclusions included: * An affirmation of the potential and general acceptance of telemedicine and its future role in the practice and delivery of health care. * There is a global need for an on-line networking of physicians and health care providers (to the named "International Telemedicine Network") for consultation, information dissemination and distance learning. * An endorsement for the establishment of a network of "International Clinics" world wide. * The need for a system of information databanks of medical information including the establishment of 24-hour response centers dispersed geographically. * Establishment of a Technical Advisory Board to assist physicians in the advancement of telemedicine. The International Medical Institute is a non-profit organization operating as a medical think tank committed to the easing of access to quality health care on a world wide basis. Membership currently exceeds 400 physicians from over thirty-eight countries. /* --------------------------------------------------------------------- */ Abstr. no 69 - PERSPECTIVES OF TELEMEDICINE IN THE NEXT CENTURY Max House, MD, FRCPC, Memorial University of Newfoundland, St. John's Newfoundland, A1B 3V6, Canada Alexander Graham Bell, the inventor of the telephone, despite his prescience, would be amazed at what has happened in his field in just over 100 years. The rapid development of telecommunication networks (including satellites and fibre optics) and the digitization of telephone networks together with the rapid development of computer chips, telephone switches and multimedia units make it almost impossible to exaggerate future advances in information technology and telecommunications in one health field. It is predicted that by the year 2000, with the development and availability of personal communications devices, it will be possible for any person on earth to communicate at any time with any other person. This will include voice, data and perhaps video and will be accomplished by a hand-held device. The next major breakthrough will be computer voice recognition to a level that can be used more or less routinely in health care. Beginning with laboratory reports and extending to routine medical practice, this technology will revolutionize the way health care is delivered. Improved picture archiving and communication systems (PACs) and the use of a "smart card" will provide care givers with instantaneous information on which decisions can be taken. Knowledge-based systems are being developed which will allow individuals to monitor their health and diseases and participate more fully in their management. This will facilitate care in the home, nursing home or small hospital. Transdermal blood tests and micro-laboratory techniques will further bring services to the periphery. These developments will be spurred by the continuing military and peaceful use of outer space. These technological changes will result in a revolution in patterns of medical practice as it now exists. With the availability of electronic learning centres in the home and the disappearance of textbooks and journals, medical education will be unrecognizable. Electronic communication will replace the written word. Despite these and other unimaginable developments, the human side of medicine should prevail as it has since the beginning of time. To ensure this, it will be the responsibility of those who develop and use technology to bear in mind human needs and to fashion all innovations to benefit the human race.